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بسم الله الرحمن الرحيم

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Papulosquamous Dermatoses

Rania AlSaiedMD

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Pityriasis Rubra Pilaris

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It is a chronic papulosquamous disorder of unknown etiology characterized by reddish orange scaly plaques, palmoplantar keratoderma, and keratotic follicular papules. The disease may progress to erythroderma with distinct areas of uninvolved skin, the so-called islands of sparing.

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Griffiths divided PRP into 5 categories: classic adult type, atypical adult type, classic juvenile type, circumscribed juvenile type, and atypical juvenile type. More recently, an HIV-associated type has been added to this classification system.

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Pathophysiology

The etiology is unknown. A familial form of the disease exists, with an autosomal dominant inheritance pattern; however, most cases are sporadic. One hypothesis is that PRP may be related to an abnormal immune response to an antigenic trigger. Case reports have described PRP occurring after streptococcal infections.

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Mortality/Morbidity

Patients with PRP can have painful and disabling palmoplantar keratoderma. Nail dystrophy and shedding may be present. However, most of the morbidity associated with PRP is associated with the erythroderma

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Sex, Age PRP occurs equally among men and

women The familial form of PRP typically begins

in early childhood and has an autosomal dominant inheritance pattern.

The acquired form of PRP has a bimodal age distribution, with peaks in the first and fifth decades of life, but it can begin at any age.

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History The familial form of PRP has a gradual onset,

whereas the acquired form has an acute onset. The disease typically spreads in a craniocaudal

direction. Patients first notice redness and scales on the

face and the scalp. This is often followed by redness and

thickening of the palms and the soles The lesions may expand and coalesce to cover

the entire body.

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Physical

Skin PRP is characterized by orange-red or

salmon-colored scaly plaques with sharp borders, which may expand to involve the entire body

Often, areas of uninvolved skin, referred to as islands of sparing, are present.

Follicular hyperkeratosis is commonly seen on the dorsal aspects of the proximal phalanges, the elbows, and the wrists

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Palmoplantar keratoderma occurs in most patients and tends to have an orange hue. Painful fissures may develop in patients with palmoplantar keratoderma.

Pruritus, although not a major symptom, may occur in the early stages of the disease.

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Nails Nail changes include distal yellow-

brown discoloration, subungual hyperkeratosis, longitudinal ridging, nail plate thickening, and splinter hemorrhages.

Nail pitting is not typical.

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Histologic Findings Histologic features are not pathognomonic, but

they are useful to rule out other possible papulosquamous and erythrodermic disorders. Features on light microscopy include hyperkeratosis with alternating orthokeratosis and parakeratosis forming a checkerboard pattern in the stratum corneum, focal or confluent hypergranulosis, follicular plugging with perifollicular parakeratosis forming a shoulder effect, thick suprapapillary plates, broad rete ridges, narrow dermal papillae, and sparse superficial dermal lymphocytic perivascular infiltration

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Medical Care Topical medications

Topical corticosteroids may provide some patient comfort, but they are believed to have little long-term therapeutic effect.

Emollients reduce fissuring and dryness, providing some patient comfort. Petroleum jelly or one of the many proprietary emollients may be used.

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Systemic therapy

More severe cases may require: Systemic retinoids Immunosuppressants likeAzathioprineMethotrexateCyclosporin

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Complications PRP can cause painful and disabling

palmoplantar keratoderma. Nail dystrophy and shedding may occur. Erythroderma is a reaction pattern of

the skin that can occur in the setting of several different skin disorders, most commonly including psoriasis, eczema, lymphoma, drug reactions, and PRP. It is characterized by generalized erythema and scales, hair loss, and onycholysis.

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Prognosis Each type of PRP has its own

prognosis. In general, the familial form of the disease may be persistent throughout life, and the acquired form of the disease may resolve spontaneously within 1-3 years.

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Pityriasis Rosea

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Background Pityriasis rosea (PR) is a common

benign papulosquamous disease . Pityriasis denotes fine scales, and

rosea translates as rose colored or pink.

PR can have a number of clinical variations. Its diagnosis is important because it may resemble secondary syphilis.

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Pathophysiology PR has often been considered to be a

viral exanthem. Its clinical presentation supports this concept. PR has been linked to upper respiratory infections, it can cluster within families and close contacts, and it has an increased incidence in individuals who are immunocompromised. As with viral exanthems, the incidence may increase in the fall and the spring.

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recent work demonstrated human herpesvirus (HHV)–7 viral DNA in both the lesions and the plasma in patients with PR.

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SexPR is more common in women than in

men. One study found it to be twice as common in women as in men.

AgePR commonly develops in children and

young adults, although any age group can be affected. Most patients are aged 10-35 years.

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History The history should include questions

about close contacts with similar eruptions. This finding is uncommon because most cases of PR are sporadic, as PR is thought to reflect a weakly contagious disease. A history of medication intake should be obtained because several medications have been shown to cause a similar exanthem.

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The disease typically begins with a solitary macule that heralds the eruption (called the herald spot/patch), which is usually a salmon-colored macule. This initial lesion enlarges over a few days to become a patch with a collarette of fine scale just inside the well-demarcated border.

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Within the next 1-2 weeks, a generalized exanthem usually appears, although it may occur from hours to months after the herald patch. This secondary phase consists of bilateral and symmetric macules with a collarette scale oriented with their long axes along cleavage lines. This phase tends to resolve over the next 6 weeks, but variability is common.

Pruritus is common, usually of mild-to-moderate severity, and it occurs in 75% of patients.

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Physical The herald patch is usually a single

pink patch, 2-10 cm in diameter, on the neck or the trunk with a fine collarette scale. It is observed in more than 50% of patients, and it may occur as multiple lesions or in atypical locations.

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About 1-2 weeks after the herald patch is seen, the generalized eruption appears, although it has been known to occur from hours to 3 months later. It consists of salmon-colored macules or patches, 0.5-1.5 cm in diameter, with a collarette scale, often described as having a cigarette paper–like appearance. The long axes of the lesions are oriented in a parallel fashion along cleavage lines, giving the classic Christmas tree pattern.

These secondary lesions most commonly occur on the trunk, the abdomen, the back, and the proximal upper extremities.

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D.D Lichen Planus

Nummular DermatitisPsoriasis, GuttateSeborrheic DermatitisSyphilisTinea Corporis

Drug induced PR like eruptions: captopril, levamisole, omeprazole,

Barbiturates, aspirin, ketokonazole

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Lab studies One must be careful to rule out

syphilis. A screening rapid plasma reagin

(RPR) test or a VDRL test should be ordered for appropriate individuals.

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Histopathology It shows superficial perivascular dermatitis Focal parakeratosis in mounds, hyperplasia,

and focal spongiosis are observed in the epidermis.

The epidermis may show exocytosis of lymphocytes, variable spongiosis, mild acanthosis, and a thinned granular layer.

In the dermis, extravasated red blood cells are a helpful finding along with a perivascular infiltrate of lymphocytes, histiocytes, and eosinophils. A number of monocytes are also commonly present.

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Treatment Emollients Antihistamines ( if there is

pruritus) UVB phototherapy ( for persistent

PR)

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Complications The main morbidity is from

pigmentary changes, which are possible with the healing lesions.

Both postinflammatory hyperpigmentation and hypopigmentation may occur.

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Prognosis The prognosis for PR is excellent.

Patients may return to work or school because they are not considered to be contagious.

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Psoriasis

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Objectives Identify the pathogenic factors for

development of psoriasis List the clinical features of psoriasis Describe the progressive

management of the clinical features of psoriasis

List the adverse effects of psoriatic treatments

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Psoriasis

Chronic skin disorder; "itch" = psora

Incidence Other derm conditions

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Psoriasis T-cell mediated inflammatory dz

Epidermal hyperproliferation 2O to activation of immune system

Altered maturation of skin Inflammation Vascular changes

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Background Epidemiology

Age Genetic Scandinavian/European descent

Risk Factors

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Psoriasis, an inherited disease

If you have psoriasis, what is the risk to:

Your unrelated neighbor? About 2%

Your sibling? 15-20% Your identical twin? 65-70% Your child? 25%

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STRATUMBASALE

STRATUM SPINOSUM

STRATUM GRANULOSUM

STRATUM CORNEUM

Proliferation

Immaturity

Neutrophilaccumulation

DisorganizedNORMAL

PSORIASIS

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Psoriasis: Associated Factors Genetic Factors:

- 30% of people with psoriasis have had psoriasis in family- Autosomal dominant inheritance

Nongenetic Factors:- Mechanical, ultraviolet, chemical injury- Infections: Strep, viral, HIV- Prescription Drugs, stress, endocrine, hormonal, obesity, alcohol, smoking

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Clinical Presentation Erythematous, raised plaques with

silvery scales Symmetric Pruritic/ Painful Pitting Nails Arthritis in 10-20% of patients

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Psoriasis: Clinical Presentation

Type Characteristics Plaque psoriasis Guttate psoriasis Erythrodermic psoriasis Pustular psoriasis Nail psoriasis Palmar/Plantar psoriasis Psoriatic arthritis Scalp psoriasis

Dry scaling patches (AKA common psoriasis) 75% Drop-like dots, occurs after strep or viral infection 12% Exfoliation of fine scales (total body “dandruff”), widespread, often accompanied by severe itching and pain 7% Pus-like blisters, noninfectious, fluid contains white blood cells 2% Seen on toenails and fingernails, starts as numerous pits, at times progresses to yellowing, crumbly, and thickened nail; nails may slough Erythema, thickening and peeling of the skin, blistering is often present. Can lead to disability. Inflammation, swelling, and joint destruction Plaque-type lesion

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Psoriatic Plaque

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Chronic Plaque Psoriasis

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Erythrodermic Psoriasis

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Nail changes

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Guttate Psoriasis

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Nail Changes In 78% of psoriatic patients Fingernails>Toenails Four changes

1. Onycholysis (= separation from nail bed)

2. Pitting*3. Subungual debris accumulation4. Color alterations*Pitting rules out a fungal infection

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Psoriatic Arthritis In 10-20% of psoriasis patients Peripheral interphalangeal joints No elevated serum levels of

rheumatoid factors (as seen in rheumatoid arthritis, yet has all other features)

Often seen in patients with nail and scalp psoriasis

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OLA Photonumeric Guidelines(overall lesion assessment)

0 = none0 = none

5 = very severe5 = very severe4 = severe4 = severe3 = moderate3 = moderate

1 = minimal1 = minimal 2 = mild2 = mild

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631 1 Leonardi, 2003; Leonardi, 2003; 2 2 Market Measures/Cozint LLP, June 2003.Market Measures/Cozint LLP, June 2003.

Othertherapies

54%

Topicalsonly

46%

The Majority of Moderate-Severe Psoriasis Patients Are Under-Treated

50% of patients with moderate or worse disease are currently untreated1

46% have topical therapy only Reason dermatologists

do not use more aggressive therapies2

Safety concerns Time consuming Cost

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Psoriasis: Treatment Lubrication Removal of scales Slow down lesion proliferation Pruritus management Prevent complications Lessen patient stress Season and climate

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Step 1

A n th ra lin C a lc ip o trie n e

C o a l T a r

T a za ro te ne In tra le s io na l S te ro id

T o p ica l S te ro id

C lim a to th e ra py M ois tu rize rs K era to lyt ic s

Step 2

P U V A P U V A +S te p 1 ag e n t

A c itre tin

Step 3

M e th o tre xa te C yc lo sp o rin eR o ta tio n a l:

1 2 -2 4 m o n thso f e a ch

s te p 3 ag e n t

Supplementary Tx

Step 4

Enbrel/Remicade/Amevive/Raptiva

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Emollients and Moisturizers

Moisturizes, lubricates and soothes dry and flaky skin.

Produces occlusive film to limit water evaporation from skin. Increased hydration allows stratum corneum to swell- scaling decreases, skin is more pliable.

Adverse Effect: contact dermatitis, folliculitis (rare)

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Keratolytics = “SKIN LIFTERS”

Helps remove scales and reduce hyperkeratosis

Salicylic Acid 2-6% Enhance absorption of other drugs AE: N/V, tinnitus, hyperventilation (rare

=salicylism)

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Tars Coal Tar – made from crude coal Decreases epidermal cell mitosis

and scale development Reduces sebum production Anti-inflammatory effects 5% coal tar concentration most

effective (1%-6%)

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Coal Tar

Problems with coal tar: Smell Sting Stain Sensitize

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Coal Tar Very useful in guttate psoriasis and for

scalp psoriasis as a shampoo Not recommended as 1st line tx:

Erythrodermic & Pustular Irritation may lead to Koebner’s phenomenon

Use only on lesions that are well separated, not too big

Phototoxic response sunburn may become erythematous

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Corticosteroids Reduce inflammation, itching and

scaling Anti-inflammatory effect

Decrease in vascular permeability, decreasing dermal edema and leukocyte penetration into skin

Antiproliferative effect Immunosuppressive effect

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CorticosteroidsLevel of Potency

Corticosteroid Commercial Products

Ultra-high Halobetasol propionateClobetasol propionateBetamethasone dipropionateDiflorasone diacetate

Ultravate crm/ointTemovate crm/ointDiprolene ointPsorcon oint

High HalcinonideAmcinonideBetamethasone dipropionateMometasone furoateDiflorasone diacetateFluocinonideDesoximetasone

Halog crmCylocort ointDiprolene AF crmElocon ointFlorone ointLidex crm,gel,ointTopicort crm,oint,gel

Mild to high HalcinonideTriamcinolone acetonideBetamethasone dipropionateFluocinonide

Halog oint,crm,solnAristocort A ointDiprosone crmLidex-E crm

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CorticosteroidsLevel of Potency

Corticosteroid Commercial Products

Mild Hydrocortisone valerateTriamcinolone acetonideFlurandrenolideMometasone furoateFluocinolone acetonide

WestcortKenalog crm and ointCordran ointElocon crmSynalar oint

Low to mild Hydrocortisone valerateTriamcinolone acetonideFlurandrenolideBetamethasone dipropionateHydrocortisone butyrateFlucolone acetonide

Westcort crmKenalog crm and ointCordran crmDiprosone lotionLocoid crmSynalar crm

Low Alclometasone dipropionateBetamethasone valerateFluocinolone acetonideHydrocortisone, dexamethasone, prednisolone, methylprednisolone

Aclovate crm and ointValisone lotionSynalar soln and crm

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Corticosteroids Ointments: helps hydrate; good for

dry, hyperkeratotic, scaly lesions Cream: for use on all areas, useful

for infected lesions Solutions: for scalp psoriasis, often

contain alcohols which can be painful with open lesions

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Corticosteroids Adverse Effects: (esp. with

occlusion) Systemic absorption Dermal atrophy Telangiectasis Ecchymoses Peri-orbital acne Poor wound healing Pyogenic infections

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Vitamin D3 Isolated from cod liver oil in 1936 Made in human skin through

reaction:7-dehydrocholesterol & UV light

Calcitriol’s properties in psoriasis:1. Increase cellular differentiation2. Inhibits cellular proliferation

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Vitamin D3 Adverse Effects:

Hypercalcemia Hypercalciuria Mild calcitriol intoxication: renal

stones Not for long term use, therefore

analogues were developed

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Vitamin D3 Analogue

Calcipotriene (Dovonex®) Indication = Moderate plaque psoriasis Reduces scaling and thickness of plaque,

but not the erythema; what would you use in combo?

Max weekly cumulative dose: 5mg= 100gm of 50 mcg/gm or 2 tubes

Applied BID x 8 weeks

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Vitamin D3 Analogues

Calcipotriene (Dovonex®) Not for pustular or erythrodermic psoriasis

due to increased systemic absorption AE: irritation, hypercalcemia (when applied

in large amounts) CI in pregnancy, lactation, children

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Retinoids Vitamin A derivatives

MOA:1.Normalization of abnormal keratinocyte differentiation

2.Reduction in keratinocyte proliferation

3.Reduction in inflammation

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Oral Retinoids Etretinate & Acitretin (Soriatane®) Second generation retinoids For pustular and erythrodermic psoriasis Etretinate withdrawn from US market-

1998 Acitretin= active metabolite of etretinate Reserved for treatment of severe forms of

psoriasis due to side effects.

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Soriatane : Dosage Usual dose: 25-50mg/day as

single dose Dosage form: 10mg, 25mg

capsules

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Soriatane : Precautions Avoid in severe liver and kidney dz Avoid in patients with h/o alcohol dz

ETOH = reverse metab to etretinate Teratogenic- CI in pregnancy

Contraception one month before treatment and at least 3 years after

Monitor: serum lipids, LFTs, serum creatinine (problematic as alternatives have similar limitations)

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Soriatane : Adverse Effects Peeling, drying skin Diffuse alopecia Nail changes Sticky, clammy skin Muscle pain Calcification of ligaments

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Hepatotoxicity 33% of patients had an elevation of AST (SGOT), ALT (SGPT) or LDHBlack Box Warning

Alopecia 50-75% of patients

Mucocutaneous50-75% skin peeling25-50% dry skin25-50% pruritus23% dry eyes

LipidMetabolism

66% increase in triglycerides33% increase in cholesterol40% reduction in HDL

Soriatane

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Topical Retinoids

Tazarotene (Tazorac®) Third generation retinoid Stable plaque psoriasis (up to 20%

of body surface area involvement) Severe facial psoriasis Water based emollient gel or

cream

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Tazarotene (Tazorac®)

Apply once daily x12 weeks AE: pruritus, burning, erythema ? More selective retinoid than

Soriatane resulting in fewer ADRs

Oral formulation pending at FDA

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Counseling points Apply a moisturizer to the skin before using the

Tazorac; it can dry out the skin.

Apply it once per day about 30 minutes before bedtime.

Rub about a pea-sized amount only into each lesion; it can irritate normal skin.

If it spreads to the unaffected skin, wash it off with water. Zinc oxide can protect the skin

Apply sunscreen

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Methotrexate For moderate-severe psoriasis non-

responsive to topical treatment MOA:

binds to DHFR which leads to reduction of tetrahydrofolate, which inhibits pyrimidine synthesis. Pyrimidine is needed for formation of DNA base pairs, therefore decrease in DNA replication esp rapidly dividing cells as in skin

Induces apoptosis of activated T cells

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FOLIC ACID

METHOTREXATE

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Response to Methotrexate Suppression of B cells and

macrophages Induces T-cell apoptosis Suppresses IL-1 and IL-8 production

by peripheral blood mononuclear cells

Reduces T cell production of interferon-gamma and TNF

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Methotrexate: Precautions Contraindicated:

Pregnancy, lactating mothers

Renal & liver problems Preexisting severe anemia,

leukopenia, thrombocytopenia

Alcoholics Active infectious disease

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Methotrexate: Dosage Initial: 2.5-5mg q12h x3 doses qweek Titrate up weekly by 2.5mg increments

[if blood counts (weekly then monthly) and LFTs (q4 month)allow] until symptoms respond

Injections: IM or SQ Max: 50mg/week, but some

75mg/week

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Methotrexate: Adverse Effects Headache, chills, fever, fatigue,

abdominal pain, nausea, vomiting, dizziness

Pruritus, alopecia, urticaria, ecchymosis, sunburn (phototoxicity)

Osteopathy- rare & at low doses Pulmonary fibrosis- CXR yearly Obtain liver biopsy after each 1.5gm Folate rx on days NOT taking MTX

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Cyclosporine

For psoriatic lesions resistant to other therapies

MOA: prevention of IL-2 transcription, prevention of primary T-cell activation and reduction of T cell cytokines.

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Cyclosporine: Dosage Oral Cyclosporine Microemulsion:

Neoral Capsules, solution Initial: 2.5 mg/kg/day split BID x4 wks May increase dose at 2 week intervals

of ~0.5 mg/kg/day increments Max: 5 mg/kg/day Relapse:

6 weeks (50%)-16 weeks (75%)

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Cyclosporine:Adverse Effects

Headaches, paresthesias, flu-like symptoms, abdominal pain, nausea.

Hypertension Nephrotoxicity:acute blood flow; chronic

form dose and duration Neurotoxicity Hepatoxicity Hyperglycemia Should be used as short term therapy (<1

year) to avoid further adverse effects (gingival hyperplasia, hyperlipidemia, hirsutism, etc).

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Phototherapy Used over 100 years for moderate-

severe psoriasis UVA (315-400 nm), UVB (290-315

nm)

313 nm = most effective wavelength for psoriasis

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Phototherapy Ultraviolet B

Relatively non-toxic Can be used as a single-agent Usually combined with lubricants Ingram’s regimen (Anthralin) Goeckerman’s regimen (Tar)

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Phototherapy

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Phototherapy

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Phototherapy

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Phototherapy

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PUVA PUVA= Psoralen + Ultraviolet A Theories of MOA:

1. Psoralen intercalates into DNA, inhibiting DNA replication and thus, inhibiting epidermal cell hyperproliferation

2. Free radical formation damages cell membrane, cytoplasmic contents and nucleus of epidermal cells…inhibiting growth of cells.

3. Increased apoptosis of activated T-cells

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Oral PUVA

Psoralen = “P” in PUVA = a photosensitizer

Methoxsalen (Oxsoralen-Ultra, 8-MOP) 10 mg capsules Given 2 hours before UVA irradiation Symptomatic control of severe,

recalcitrant disabling psoriasis, not responsive to other therapy after biopsy confirmed diagnosis

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PUVA Phototoxicity

Related to quantity of psoralen and amount of UVA applied

Reaction peaks 48-72hrs after treatment Erythema, blistering, edema

Administer 2-4x/ week Tanning occurs, so gradually increase

dose of UVA ~20 sessions over 4-8 weeks clears

lesions

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Oral PUVA: Adverse Effects Constipation, diarrhea, nausea,

vomiting, pruritus, delayed-onset erythema

Oral psoralens distribute to entire body and eyes: protect eyes and skin from sunlight 6 hours after treatment

Long-term: premature aging, cataracts, skin cancer (rare)

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First Generation Biologicals Infliximab & Etanercept:

immunomodulators used initially for rheumatoid

arthritis; work against TNF-alpha

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TNF Inhibitors Both Remicade and Enbrel are quite

effective (>75% of psoriatics respond) even if only skin is affected

Enbrel SQ once* or twice weekly; Remicade IV0, 2 and 6 weeks

Concerns: exacerbate MS and TB, induce SLE and CHF, palliative not curative

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New Therapies Alefacept (Amevive)

Inhibits CD45RO+ memory effector T lymphocytes, by binding to their CD2 receptor also leads to apoptosis

Administered IV or IM qweek x12 wks

AE: dizziness, chill, nausea, cough